whatever money they have not accounted for. i welcome conversations with any of these federal agencies because it has to change. the american people are demanding it to this insensitivity and unresponsiveness has got to change. what happens is among providers like you and others, the most compassionate and caring people i've ever met, i spent four years in this career. let's face it you're not going to get rich with what you do. you love the people you're working with and because you're always so divided help. that's altruism. federal agencies onto the attention to that. get outside the beltway and different people what we need to be doing as providers. >> we decide about a minute left. soak quick question from this side spent unfortunately it's kind of loaded. executive director in washington, d.c., sort of a tongue twister some going to read it off. how does you address the need for culturally, cost of cultural

step to ensure culturally competent care in compliance with the national culturally and linguist with appropriate service stands and legislation? >> so is already required? >> of different states space are you think is already required? >> that's what i'm trying to explain the i think it is the states mandated. 13 is on the table and a couple have vetoed it. >> what state individual do is up to them but certainly along those lines were because it's valuable. i just think it's a federal regulation? >> i'm not familiar with the process. i'm just learning spent because the extent that those are out there, what we're doing is trying to pick up the slack for a of the agencies that have not paid attention to the. i think it's about to have a password want to make sure that for access to providers who are minority numbers and being part of communities and being out there. we have made major changes from her first draft to the current

one. we are working on other things. we recognize it's a java part of the nasa change that people do have a cross-cultural sensitivity to help us take on this. we want to do the if you of the wording language, glad to look at that. >> thank you so much. i really appreciate your time. we appreciate you for being here and really engaging in a beneficial conversation. >> thank you. i hope america will speak out. [applause] ♪ ♪ an spent please welcome the honorable chris murphy. [applause] >> thank you very much to "national journal," janssen pharmaceuticals for having me

here today. i got to listen to a bit of my long lost cousin tim murphy's presentation your you know, i read once a thousand page history of our homeland, ireland, and i kept on waiting for the murphy's to show up in this history to talk about all their great deeds. i flipped onto the indexer that the that in a thousand page history of violent there's only one single murphy that shows up anywhere in it. and so would like to think that we waited to to our good deeds into we came to america, but it's great to be here with tim has been a wonderful partner in this effort. and thank you to all of you for ever fantastic turnout this morning. we do both in the house but particularly in the senate, given the we've had a little bit later start up taking this issue seriously, that there is momentum in any way behind

attacking the behavioral health crisis in this country. and i will maybe finish my remarks by talking about the political context and some of the thorny questions about how to talk about mental health in the context of these mass shootings. but what we know is that this has been a crisis for a very, very long time. and it's nothing new for families who have been dealing with it for a long, long time as well. for all of us this is a personal issue. for tim this is a personal issue because it's been his livelihood, his profession. from a of the rest of us this is personal because we watched close family members try to navigate a system that simply doesn't work. i often say that my family has a long, proud history of mental pressure i said because we talked about it in my family, not unlike we talk about our

cuts and bruises and scrapes and our broken bones and our predisposition to heart disease. we talked about the fact that we also have a history of behavioral health in our family, and we've been lucky enough to have the resources and capacity to navigate through a very complex system. but we know in my family that others don't, and that's really what this piece of legislation is about to finally get answers to these answers if you like a hit a brick wall after brick wall. we set up the community health system in the 1960s, one of president kennedy's signature pieces of legislation, it was called a bold new approach at the time. and it was. this was our effort to close down what were at the time called insane items, and move people with mental illness out of institutions and into the community -- insane items.

and it was the right thing to do. but over the intervening 50 years, we've encountered two major problems with that bold new approach. the first is that we never properly resourced the community care necessary to properly care for the people that lifted these institutions. imagine what happened is that many of them didn't get served and died. others can't read institutionalized in the emergency room's or prisons. we just didn't keep that promise as we often see in connecticut in the wake of that community mental health reform. but the second thing that happened is that by virtue of our concern for setting up a new community health system ended up compartmentalizing mental health and behavioral health walled

away from the rest of our health care system. and we all see it today. we have community health care clinics and we're proud of that we invest in, but as we increase in understand how the entirety of the body works together, and, frankly, as we increasingly understand that by treating mental illness in a wholly different physical space, with a wholly different reimbursement system, with a wholly given set of insurance rules, we really perpetuate that statement. and so the legislation that we've introduced, myself and senator cassidy in the senate, and tim murphy and others comments are is about building new capacity. we've got some major medicaid reforms which is going to attack the diminishing of the 4000 inpatient mental-health beds and 2007, that will allow for more people to be able to see primary

care and behavioral health clinicians on the same day. but it's also no trying to bring these two systems together the i'm particularly proud of the program in our bill that would provide grants to states to try to break down the existing regulatory barriers to the coordination of physical and mental health. what i hear about in connecticut is that community mental health clinics in community primary care clinics want to collaborate but because states regulate them differently they have a hard time working together, even a harder time co-locating or are legislation really is designed not only to add capacity but also to try to get these two systems working together. and we hope that by doing that we are attacking this stigma, that we're not just making the system work better but we bring the system together as well. but we also hope that there are other parts of a bill that

attack that statement. we take the next step in parity in the senate bill by forcing insurance companies to disclose what all of their bureaucratic hurdles our to the guarantee of parity that we passed several years ago. we give the administration new enforcement powers to actually make real that guaranty which is in a lose rate for far too many. we attack the discriminative and in a way that research is a done by setting up new research organization that will specifically focus on best practices for the delivery of mental health and to start challenge our colleagues to put money into that research just like we're putting it into other types of research at nih and cdc. and i will tell you we are hopeful that there are serious momentum behind the spill innocent. we introduced it right before the august break but already we have five republican cosponsors

and five democratic cosponsors. this week we just added our new pair, senator capito and senator schumer. next week we will announce another. we have a longer line right now of republicans then we do democrats who are waiting to get on this legislation which is wonderful to have as a problem, and we feel like with a hearing scheduled in the help committee later this month the first thing in the help committee on mental health in three years, that's amazing to think about, that we are poised to move this bill. as my time is up, before i sit down let me just spend two minutes talk about the context of messaging. i know that we're talking about this in a more robust way because of the issues. i went to the floor yesterday to challenge my colleagues, to understand that the mental health system, the behavioral health system has to be fixed because it's broken, period,

stop it ever should fool ourselves that we are going to cure the nation's epidemic of gun violence by fixing a broken mental-health system. why? because attended has a gun violence rate that is 20 times that of all of our other competitor a we see beijing -- oecd nations and yet there is no evidence we are spending more money at a greater rate for mental illness in this country. there's something different about the kind of but is not necessary in our behavioral health system. i don't deny to fix some of the gaps they will have a downward pressure on violence. but we have to be very careful over the coming weeks and months of debate of falling into the trap which tries to define america's growing gun violence epidemic as one that is rooted in a behavioral health system. i don't mind conflated the two because i think that will

ultimately help to make our behavioral health system better, and if this is our opportunity at our moment to try to pass something, then we would be fools not to take it. ultimately, we are not going to fix that can by this epidemic in this country if we don't get serious about what differentiates ourselves from other countries. this is not a forum to talk about that, but it isn't necessarily a question surround our behavioral health system and how we fix it. thank you very much for having me. i look forward to the debate. [applause] >> please welcome back lauren fox. >> thank you so much for joining us today. i want us to start with the bipartisan nature of this bill. a rarity in washington, d.c. can you take us behind the scenes about this issue became

so bipartisan come what it's been like to work with congressman murphy and others, senator cassidy in the senate? >> i give a lot of credit to tim. tim is a good friend. he really set a precedent for bipartisan cooperation in the house by building a robust group of republican and democratic cosponsors. when i decided to really dive into this issue at any level at the beginning of this year, i decided that the most likely vehicle that was ultimately going to become a law was going to be the one that has the biggest amount of bipartisan support and after i said listen to either the i agree with everything in your bill and i do know that i can. i'm going to introduce a carbon copy, but let's try to do companion bills that have the same foundation with maybe some different branches that come off of them. bill cassidy was very involved in tim's bill in the house.

so we said to me early on he should talk to bill cassidy about this because he would walk into timber things hearing with a dogeared copy of the book crazy, which many of you have read and is a guidepost for a lot of us who care about this issue, so i approached them and he said that he wanted to dive in along with. we spent a long time working on the draft of the bill. it is largely a companion bill to the house national we've got some things are different, although more focused on prevention, more focus on coordination and i have been very pleasant surprise at how fast our colleagues have signed a. we rolled out the bill with myself in simvastatin and send franken who on our site are done the most work on mental health. on his site it was him, senator collins and seven are bitter. we've added since then senator capital on their side and senator murkowski.

i think will add more quickly. i think what this will become is a bill that hazwoper support on a bumper support that's actually sort of a cross section of ideology with each nation within each caucus. it's progressives, moderates, conservatives, moderates altogether until the a pretty important signal to leadership. >> i want to give you an opportunity to address this at the end of your speech, but we've often talked about mental health legislation in the context of the candidate and there always seems to be more discussion and momentum after a tragedy occurs. does that stigmatize mental illness? is that a concern of the? >> this is an incredibly important topic and have talked openly with my colleagues especially the democratic side of the aisle about how we talk about this. what we know is there's no inherent connection between mental illness and violence, that people with mental illness

are 10 times, 20 times more likely to be the victims of violence than the perpetrators of it. and we do risk perpetuating this stigma, and we see it play out in really disturbingly open and blatant ways. remember the germanwings plane that went down in europe? remember the conversation that was openly point out a major cable news networks after that, someone with a history of depression shouldn't be allowed to fly a plane to kosovo is a connection between depression and a desire to take down a plane in an act of mass murder? that's ridiculous but it shows that these people make this connection between mental illness and violence that doesn't mean we should recite the opportunity that's been put in front of us to bring this bill to the floor but it's why yesterday i went down to the floor and gave it specific speech calling out my colleagues in that if you really want to

take on gun violence, then you have to take on a celebratory culture of guns in this country. you have to accept the fact that what makes us different from other nations is not the amount of money we spend our behavioral health. we can do much better. what makes us different is the fact that when people have a dispute in this nation, and people are dealing with internal demons, they go reach for a shotgun to try to settle their disputes. that's not what happens in other countries. i think it's important to add some lines of clear distinction as this debate goes forward. >> i want to talk about your bill and what it does to identify and help young people who are diagnosed with mental illness. obviously, getting to individuals earlier can be very helpful in the treatment long-term. >> so we've got a very specific program in this bill which would engage and investing early intervention. so our bill starts the program at three years of age but we've

heard a lot of feedback. i've done 11 or 12 roundtables in connecticut and one of the things we heard loud and clear is we should move to zero. early intervention programs that really identify individuals or showing those warning signs of mental illness, serious mental illness and give them resources and get their parents resources up front. that they'll continue to make a down payment on things like mental health first aid, which is a program of early identification by people who are watching kids from daycare providers, teachers, social service personnel so that we can find the kids and get them into treatment. and then again it's just a matter building capacity. i would avoid one of the most important things in this bill is its ability to see a primary care provider, and then on the same day be able to see mental health clinician. a lot of these kids are coming in to see pediatrician but when

they get the referral to the behavior health provider, either they can't find someone or the logistics of getting to them just becomes too big for families that have a lot of economic and social challenges. so called location of primary care and behavioral health which will be each others but they forget a lot of kids who are seeing their primary care physician pretty regulate into behavioral health treatment spent i also wanted to talk just a little bit more. your bill calls for hhs assistant secretary for health. symbolically what does that say about how it changes americans view of mental health issues? and also logistically what does a new role to? does it great sort of organization or are there fears it could create more bureaucracy? >> this is a subtle but maybe important point of distinction between the house and the senate bill.

we keep samhsa impact in our bill. we think there are ways we can reform samhsa but we don't think it is necessary productive for and is worshiped to be eliminated. we do so parent tens of bill by setting up this new assistant secretary. usual we are coming from. what is frustrating is that most all of the serious conversation debate about mental health and substance abuse is happening within samhsa, which is controlling a tiny portion of the federal government spent on mental health and behavior health and substance abuse. most all of them and that is being spent on the program is happening within medicare and medicaid. and yet there is no one sitting next to the secretary who is thinking creatively about how you use medicare and medicaid in order to advance the treatment models in behavioral health.

the new comparative research center set up under the health care law is actually doing more work in behavioral health research and our on any other sector research and they said it was an accepted that the unexpected but they found his giant lack of research and the best behavior health practice models that are trying to fill that. but it is not somebody in the sector's office who is translating what a group like this can happen to making sure that is infused into the way that medicare and medicaid were, then we're really not getting the biggest bang for our buck. samhsa is important that you get somebody who is overseeing the big mental health staff, not just the targeted dollars. >> how do we ensure that insurers are following through with the changes made in the affordable care act? is a more that can be done speak with they are not following, they are not. and we hear on a daily basis that insurers have just taken

this guarantee of parity, that you could technically covert behavioral health want to cover physical health and erect so many barriers to getting that behavioral health benefit that it just becomes meaningless often, and the stories are heartbreaking that we get. what do the things i'm struck by is when you walk into an emergency room in connecticut and you've got a broken leg or a bleeding ulcer, you get treatment immediately. but if you walk in with a complex behavioral health issue, let me correct that, when you walk in at night. when you walk in and night with a this is you get immediately to do. when you walk in at night with a behavioral healtbehavioral healu sick in hospital until eight or nine the next morning. nobody touches you ca come noboy treats you. nobody evaluate you. they won't touch it until they know that they can sew it on the phone at pictures coming to give you the prior authorization for treatment.

for the warehouse you overnight. physical health doesn't require that prior authorization. but for some reason the brain is different. the brain requires prior authorization. what we need to do is what this bill does which is shed light on the processes these insurance coverages to try to deny treatment and to give new enforcement mechanisms to the federal government to go after companies that are violating the law by essentially doing an end around with these bureaucratic hurdles spirit of want to give the audience a chance to line up for questions, those will start in about three minutes. either local or state programs that you view as leaders on this issue? you started digging in. have you discovered then she thought this is a great idea, this is something we should be doing on the federal level? >> shore. i think both our bills are infused with work that we've learned from state governments.

program specifically designed to to early interventions on schizophrenia since our state programs that are not funded in this bill. we have a wonderful but simple program in connecticut and a couple other states as well that invest for primary care physicians who encounter a patient with a complex behavioral health diagnosis to call up immediately a behavioral health clinician who will do an immediate in person phone council why the patient is in in the office. so rather than to send them across town to the behavioral health clinic you can get animated conversation on the phone. we are doing that in connecticut and it is getting rave reviews and really good outcomes. we pilot program that in this legislation as well. we really do believe a lot of the innovation starts at the state level and the house and the senate bill both i think

involve a number of programs that come from the grassroots. >> even the one in five adults is diagnosed with some kind of mental illness each year, the number of psychiatric beds has decreased dramatically by 14% in recent years. do you do that is one of the biggest barriers of care ask where do you think that in terms of ensuring that people get the care that they need? >> that's at the top of the list. i guess i haven't gone through the trouble of ranking all of the terrible problems that we have in our behavioral health system. that would be far too depressing. but that's at the top of the list because what's happening is that people are just sitting in emergency rooms for days and days and days, but they're also beethat this credit and pressurn the backend, whereby the people are in the institutions are being pushed out before they're

ready. and we just heard that story over and over again in connecticut. a woman tells a story about her son who committed suicide the day after discharge from hospital, and she begged for him to stay. not clear what it was the hospital pushing up to make room for the insurance company pushing out because he didn't want to put but his mother and he was not ready to come home. he was not stabilized. up when you've lost 4000 beds since 2007 there is is only semi-places that you can go. this is going to be the challenge. our two bills make two major changes. they get rid of the i am the explosion. you can start building inpatient capacity they can and then they allow for the same taeo by the wayside. those are going to cost money. we have got to make the case to our colleagues that you cannot fix this problem if you resource

it at the level that it is today. in this budget and private bath very, very difficult but it's not going to be enough just to rearrange the deck chairs. you've got to make some serious investments. that's going to be easy but tim and i am bill and others working on this are committed to it. >> i wanted to make sure, it's time for audience questions from the people of not only asked the question to get an opportunity. object spent on soccer i think we just need to make sure that there's new voices in the discussion spent mr. murphy copy off before i could ask my question to thin to a very brien you ask your question? >> i just look at the very first line of murphy's law, or proposal, and you started talking a statement as well all right, and he quoted violence, 10% of untreated psychiatric

disorders result in some sort of violence, and you're concerned about stigma. here i quote the very first light -- >> can you ask your question? >> untreated serious mental illness in recent ask of mass violence. so the very first line of that immediately connects the violence for those of psychiatric diagnosis. >> i think i spoke to this. very intentionally. i think this is amongst the most important questions we have come how do we acknowledge that we are talking about behavioral health reform come in part because of these episodes of mass violence without perpetuating and creating this statement. so again i have been a very outspoken on this matter. we should fix our behavioral health system because it is

broken, full stop. to it doesn't mean we should forsake the opportunity to fix a behavioral health system but it's a very, it's very dangerous if we talk about this in the wrong way. >> thank you. [inaudible] >> go ahead. >> how are you doing today? can jimmy? my name is jennifer. my son matthew, i am here from orange county, california. i'm a family member of one of the 4%. as a member of the 4%, our voices are not generally shared because our family members are too sick to speak up for themselves. they are not well enough to find a way to a meeting here today to advocate against civil commitment reform, fear mongering because they think they will get locked up because they are homeless under a bridge. so they are too sick to advocate for themselves so we have to come there to advocate for them. so my question would be, what

are you doing to address the needs of the 4% of those who lacked insight like my son who is institutionalized from age 12-18 because he did respond to a current medical treatment. there was no brick wall for our family financially. fas..

get a plane ticket and their shoelaces and go back home to our communities upon which there are no wraparound services for people like my son because they choose not to participate in services because they're not sick. so the question is, how, is your bill going to address the needs of the population upon which we don't even know how many exist because no one is tracking them until they wind up incarcerated? he walked into a bank pretending to isis off his meds, said he would blow the place up. he is serving 14 years in state prison. he doesn't have meds. it is a known population. how are we addressing those voices? how are we representing those families and looking out for families of the monster. >> thank you, i'm sorry.

>> so, that is a big question, right? [inaudible] >> basically, these tragedies are not a surprise from our vantage point. >> yeah. >> they're not a surprise. we're not trying to connect violence to all mental illness, i tell you right now, i've been screaming 17 years for hope. it's a known population we're dealing with and how are we dealing with. >> i know we have a long line. let me try to answer. one, you've got to empower parent and families to be more involved and current hipaa laws don't allow that, when your child becomes majority age, you're all of sudden cut out of decision-making process. both of our bills contain changes to hipaa laws to allow parents to be more involved. when i go to the behavioral health community, i say for very complex behavior kids, who is in charge? everybody looks at each other.

nobody really has an answer, right? some people say, well the school, social worker is in charge. some people say the primary care physician is in charge. some people say the mental health fizz is in charge. we have to answer that question. my belief, you change the coordinated systems, change the way you pay for health care, so you're requiring systems to coordinate across reach other, and to get paid based on how healthy they keep people, rather than how sick they keep people they will solve some of those questions of leadership. so, no, listen, i, the reason that tim and i are doing this is for the people like your son, right? that is the reason we decided to dedicate our legislative lives to try to fix this. i'm sure we don't have all of the answers. probably not even 25% of the answers in this bill but we're trying. >> thank you so much. do we have another question?

>> yes. senator murphy, my question is, if the imd exclusion is lifted or partially lifted, i probably effectively completely lifted, and there, the money will go, some of the money will go to state psychiatric hospitals, but there is no, is there a requirement that the states that then divert their medicaid match to help pay for that hospitalization, maintain funding for medicaid services and community mental health systems? because the state funding for mental health is only back to where it was before the recession. >> right. >> most all of these expansions of federal dollars include a maintenance of effort provision. i will double-check on that, within our bill. that's certainly our intent. to make sure you're not

stealing, robbing peter to pay paul. >> i'm not aware that is in your bill. >> be glad to take a look at that and follow up. >> have more questions on either side? i have, just one more for you, senator. i wanted to talk a little bit more about when you're talking about issue of mental health, obviously there are a lot of stories and a lot of people very passionate about this. do you find, in your conversations that sort of mobilizes you, keeps you going, ensures you can to to leadership that this is worthy of getting floor time and are you optimistic this bill will move forward out of committee? >> to be honest i think it goes both ways. the reason i think we've grown this robust, bipartisan list of support because the issue is personal. i imagine every single person that signed on the bill doing it

in part because they intellectually understand the challenges that are confronted by people in this audience but they also have a personal story as well. but, i will be very candid with you. the deeper i get into the issue, the more time i spend with families, the more complicated the solutions become to me. you know, i started out by saying that my family sort of thinks about behavioral health the same way we think about physical health and that's the way we have attacked the stigma, to say the two are identical but they aren't. mental illness is often wrapped up inside of trauma in a way that complicates and compound it and it has to challenge us to think differently about how you address the underlying issues. you know, if you have a broken leg you really can just put a cast on it and it will be better but if you have a complicated behavioral health illness, it

may not be that you just need to treat that individually. you may also need to treat the support system around that individual. you may have to reach out to the parent of a child or the siblings and talk about some of the issues that have compounded the behavioral health issue by surrounding trauma. i remember going to our biggest inpatient psych unit for kids in connecticut. they had 16 kids in the unit. i asked the director, how many kids also have trauma histories. this is behavioral health unit. he looked at me, all 16 have trauma. it inspires me when i hear a story to do better but it also made me understand that you will have to approach this new holistic system where we're building in a slightly different way, than you might approach a physical health or primary care

system. you have got to challenge the system to have the resources to reach out and treat those around and help those around the individual, not just target the individual. >> congress is obviously working on this in a bipartisan way. is the white house engaged on this issue? have you been talking with them at all about sort of prospects of a mental health bill? >> the white house has been engaged. i would love for them to be more engaged frankly. and so, we've clearly been working with hhs and with our proposal as has tim. i'm not sure yet who is going to be testifying at our hearing in the health committee later this month but i imagine the administration will be there. you know, secretary burwell is serious about this issue. obviously she is very, very bold in her reform proposals how hhs and cms reimburse for health

care and we want to make sure as they're building this new model of rewarding outcomes, rather than rewarding volume, that they are also that for the behavioral health system. understanding that in the behavioral health system there is frankly a greater connection between the volume of practice and cost than there may be in other parts of the health care system. that really one of the things we're lacking in the behavioral health arena, is the volume, enough visits, is there enough beds. so we want to make sure this payment delivery system reform is really thinking about the unique way in which it has to encompass the behavioral health system. >> i want to thank you for all of your time, senator. i really appreciate it. >> thank you. >> this was a very productive conversation. >> thank you very much. >> thank you. [applause] ♪ >> please dr. renee binder,

president of the american psychiatric association. dr. kathleen nolan, national association of medicaid directors. jon snook, director of the treatment advocacy center. mary gilberti, national liance on the mental illness. dr. fred observe sherr, -- oshe, council of state governments justice center. [applause] >> i want to thank you you all for joining us today. i hope we have a lively exciting discussion here on stage. i told the panelists, i hope you interact with each other. i have a couple questions individually. please feel free to weigh in when we talk about this. obviously there are a lot of perspectives and voices on issue. we want to make sure we're all represented here. i want to start with dr. binder.

i want to ask you to address this issue of parody. i think has come up with a couple of times with both senator and congressman murphy. is there a better way to address this? what do you view as the way to insure insurers are being fared about the way they treat mental illness compared to physical illness? >> parody for mental illness is the law right now but unfortunately it is not always the case. and there needs to be better enforcement of parody. the problem is that the people who are not getting parody, are often people who can not advocate for themselves. and, one of the things for example at the american psychiatric association, is doing is we have developed educational materials, we have developed posters, we are asking every psychiatrist in every

clinic to have this poster up in the clinic and the poster says, you are entoiletted to coverage for your mental health care in the same way that you are entitled to coverage for your physical care. if you are not getting this coverage, then this is what you need to do. this is the number to call. this is how you take care of it. so we need to let people know what they need to do when they do have parody. >> go ahead please. >> we did a report last year when we asked our members what they were experiencing with respect to parody, denials for medical necessity and mental health were twice as much than physical health care. networks, we heard a lot about that, were completely inadequate. people couldn't get access to care and concern about he had incations, having access to full a ray of medications under plans. we found a lot of problems when we talked to our members about

enforcement. >> this is burden for people dealing with mental illness to report issues of parody. bureaucrat i can i assume and difficult to get through. >> very. >> i wanted to also ask, jon snook, treatment advocacy center focuses on eliminating barriers to mental health. what is the biggest obstacles for individuals getting medical care in your experience. >> sure. one of the biggest, you heard it discussed already today, the idea we haven't kept our treatment laws up with the science. we have a situation now where everybody in this room realizes if you have a severe mental illness and you're in treatment, you're no more likely to be dangerous than anyone else. but at the same time, we have treatment laws that say, you can't get help unless you're a danger to yourself or someone else. so what that means is, if you're a person who's ill, who needs care, you're left to your own devices until you get so sick, you're actively violent to

yourself or someone else. that is not how we treat any other illness. i'm so excited, senator murphy, congressman murphy, are really taking test to say we need to change this. >> i wanted to kind of going off of that, is there a way to inter screen earlier and what have you all seen in terms of successful programs that intervene much earlier? >> i think there are any number of ways. we see working in the states, and that is one of the nice pieces of these bills, they allow states to step in, to take those sort of next steps to make sure people get the care they need before they're a danger, before they're sick. and, what the reality shows is that, if you treat people before they're at this level of crisis, it's cheaper, it's more effective and people do recover. >> if i could add to that? >> yeah. >> coming from the medicaid perspective one of the things they're working really hard on,

what we call integration of physical and behavioral health. one of the opportunities that comes from that, finding people before they're in a crisis. so have regular sources of care that just don't consider your physical health outputs and your physical health status but actually are better able to spot issues that may have behavioral health ramifications or symptoms. so by bringing the previous speaker talked about colocation, some of those ideas where you're trying to think about the whole person actually can do better at spotting things early than with we're only classifying you needing behavioral health when you're in the office and seeing those very providers. >> go ahead. >> there are a lot of early intervention programs. you're right, early intervention is very important. so there are programs in the states which target people, young people, who might be developing early signs of

schizophrenia. so an adolescent or young adult who's thinking is maybe a little bit off. maybe they're not tracking information. maybe they have some unusual ideas. so they can be brought to a psychiatrist, and the psychiatrist will do a comprehensive evaluation to try and determine, are these early sipes of psychosis and of schizophrenia? if they are, there are very effective programs to get these young adults into treatment very, very quickly. and to try to prevent full-blown schizophrenia. there are also programs in schools to try to identify children who have early problems. there is a program called, typical or troubled, which targets teachers, who are often the first people to notice. so the teacher will wonder, is this typical behavior of an adolescent? or is this an early sign of some

problems? then they're not supposed to do the valuation. they're not qualified to do the valuation but they identify it, and then they can refer the young person to a mental health professional to psychiatrist, to do a detailed evaluation and to say, does this young person need additional intervention and maybe hopefully we can prevent future problems. >> go ahead. >> i also wanted and wholly support the notion of prevention as a thrust of our community mental health system. i wanted to just address the next step. we can't always tell or predict when an individual does have mental health crisis. that it really is incumbent on all our community to have robust crisis urgent care capacity. those people in need, in the middle of the night, on a weekend can easily access care that can address their significant mental health

symptoms at that point in time. far too often, without alternatives, the path of least resistance to take that individual to a local county jail which is not the place where people should be that don't pose a threat to public safety. >> fred is exactly right. you have too many situations right now and the imd exclusion goes very far to fix that. in many communities what you have is doctors triaging saying, well this person is sick and needs care but probably not going to hurt anybody tonight. so we're sending him home because we need that bed for somebody who is even more ill. that is terrible way to treat people. imagine from your family. you heard from families today. you're lost. you have no options to care for your loved one. you're worried they are going to be the next headline. that is a terrible way to do things. >> dr. osher, i want to piggyback on that, discuss people with mental illness who end up in the criminal justice

system, we have research on that. what can local law enforcement do to preempt that population, work with them or once people are in the system, create programs that make it easier or less traumatizing? >> yeah. so that nexus between behavioral health an[ecriminal justice is one that is really important for us to explore. just as i applaud the bipartisan approach to senator murphy and representative murphy have taken to mental health reform issue, so too do we need collaboration across the behavioral health and criminal justice spectrum. with regards to law enforcement, we have about, almost two million people each year with mental illness in our jails and in our prisons. many of whom don't pose a risk to public safety. what we have seen, is law enforcement agencies around the country, developing specialized police-based responses. most common of which, crisis intervention team which those officers learn about mental

illness, learn how to dees can late situations when they encounter them in the field, then given alternatives to incarceration for those individuals and seek that care. that is really important component of an overall strategy to reduce the prevenes of mental illness within our jails which are filled with with mental illness, four to eight times the rates of mental illness in the population. every county around the country is struggling with this. a national initiative called stepping up, and justice center and american psychiatric association foundation, national association of counties, nomi and other groups come together to say the status quo isn't acceptable. there are intervention we know work. we need to bring them to scale and drive the prevalence of people with mental illness in our jail settings down. >> at nomi there are a lot of programs and you guys advocate

for individuals. do they have knowledge to access of care or knowledge it exists? could there be more done to expose programs that are out there? maybe that is one of barriers of care? >> sure. we take thousands of help line calls every year. people don't know where to go for health. they have no idea if there are crisis services in their communities. most often they think they have to choose between the police and no care and so it's absolutely an issue of knowledge but then there is the issue of there isn't sufficient service there. i can't tell you how many times i tried to help families try to find help, the help is not there. it is not covered by insurance that a big problem people experience. it is not available. beds are not available. there is nowhere for people to go. it is a none problem and also an access problem. we say we want people to have early, easy, effective access to care, effective being evidence-based.

lots of times you get care and there is no evidence it will help you. we know what works but people can't get it. >> i want to address the issue of sort of rural communities and care versus urban centers maybe there are some more sources and programs available. what do we do with individuals who don't live within 20, 30, even couple hours from mental health care centers? >> i can jump in here. in the medicaid space we've, i think there used to be a bias that face-to-face was so important. and only way to deliver these types of services. and we are increasingly in both physical and behavioral health space using more and more technology and supportive things. telepsychiatry is something a lot of rural community are really trying to tap into. and to be able to care for people in their community. i think that is really the most important aspect that we have. access in your communities. then being able to continue your care in your community.

so we have a couple of things like telepsychiatry and telecounselling but there is also the need not just to support the individual in their community but the community providersmay not have the expertise to deal with those. so we have a couple of examples of states who are really trying to essentially use, vermont uses a hub and spoke model where you have a center of excellence that may treat people in crisis or do some interventions but then helps work with the community providers when that individual returns to the community. those models that support the individual in their community and providers in that community to care for them and maintain their continuity is really important. >> i want to ask at medicaid, sort of what do you see as maybe some of the shortcomings of the programs and how can legislation help to sort of expand coverage? >> so i think, some of the shortcomings are, i'll set aside the issue of access.

because if it isn't there to purchase, we as payers are really struggling but there are some, i think the one has come up the most frequently that is a barrier right now is the exclusion of imds. i will assume a general level of information in the community, in the audience here about what that is since it has come up a few times but the issue that leaves for us, there are sometimes a need to have these individuals in what would be called an institution, for a short period of time but we drop them out of the system of medicaid. when we do that right now. with the imdmd exclusion we can't keep them in continuity of care environment in one of the imd facilities. we have to figure out a way to include imds in our systems of care but not to flip the switch. we are not looking to warehouse people and put them back in the

hospital. that exclusion of that facility type or some of those facilities from our continuity of care is really concerning and really a challenge to take care of people. so bottom line the imd exclusion is one of the biggest barriers for us in really getting to a stronger system of caring for people with behavioral health needs. >> thank you. we have all sort of talked about mental health courts. i want you all to sort of weigh in what you've seen, whether they work, whether they need to be larger scale in order to be more effective? what have you all seen? >> so mental health courts are very effective for appropriate patients. so the way that it works is that a person who has committed a crime and they have mental illness, is approached by the public defender and the public defender says, you have a choice right now.

i'm your defense attorney and i will defend you but we know you did the crime and we know you will stay in jail or go to prison but you have an opportunity here. i can go to the d.a. and i can try to make your case that you need mental health services but you're going to have to participate in it. we'll have to go to the judge and say this is appropriate for you. and the services involve medication, seeing your therapist, substance abuse treatment. it may involve housing, and if you are willing, we can keep you out of jail and you will no longer be a defendant. we will change your title to a client right now. and it is very effective. i have done a couple of studies on behavioral health courts in san francisco and what it shows is that people who participate in mental health courts, in

behavioral health courts, if you follow them over a period of time, if you compare them to similar kinds of people who have committed the same sorts of crimes, have the same mental illness and do not participate in mental health court, there is decreased incidence of violent crimes and a decrease in jail times. so that is really an effective way of getting people out of the criminal justice system and into treatment. >> yes. >> certainly i support mental health courts as a tool within our tool box and really appreciate dr. binder's work in this area. it is the case that they tend to be small scope and number of clients and participants are relatively small. for those selected clients, it is opportunity to get connected to care to move forward in their

recovery. it is also the opportunity for the judiciary, to learn more about needs of defendants with mental illness. the smallness make it tool and not the solution. they are part of effective mental health robust system. at very core what we're talking about today improving behavioral health responses so a variety of mechanisms that are well-articulated and known can work effectively including mental health courts. >> just to pick up what fred is saying, the treatment advocacy center fully supports mental health courts but we have to recognize the existence of mental health courts is a recognition that the system has failed. mental health system fails when we have to arrest someone for them to get treatment. so the programs like aot, assisted outpatient treatment, we talked about a little bit earlier is a mental health court without having to be arrested. we're talking about states not using it. states having it on the books

but not doing the work they need to have it effectively implemented and that is a systemic failure at that i think congressman murphy touched on. for too long we allowed the system to say, he is a difficult patient, he will be a lot of work, he will be expensive and we'll let him go and jails will take care of him and that's a failure. >> i want to remind the audience we have two minutes to questions. so line up. obviously a lot of voices and expertise here to discuss these issues. i want to talk just about not just access to care, are there enough doctors, are there enough trained professionals to deal with clients? that's part of the barrier to care. can any of you sort of address that? >> as a psychiatrist i can say there are not psychiatrists. there is a workforce issue, especially when we talk about child and adolescent psychiatrists where there are even more problems. now in these bills that have

been introduced in congress which the american psychiatric association supports, where there are solutions, in terms of increasing the workforce. and it is absolutely necessary. now we may never have enough psychiatrists. that's where we get into the kinds of programs, such as telepsychiatry. so if a psychiatrist may not be available in that particular community, you can see them, they can do an evaluation over long distances, in integrated care clinics, in rural areas for patients who are disabled or elderly and they can't come to the psychiatrist's office. >> i think one of the biggest challenges for medicaid is, when there is a shortage, we have the hardest time competing for those providers. we frequently don't pay as much. we acknowledge that. we often have people who could be considered as you said, more difficult to deal with.

they don't come in. so we have a very hard time when there is a shortage, it doubles down on our most vulnerable people who need those services the most. even when there is a psychiatrist available in the area we often have a hard time making space for medicaid patients to see them. >> families call that medicaid card a license to hunt. you have to hunt for care. >> reimbursement for medicaid is very low. in my community, i live and practice in san francisco. the psychiatrists say that for patients who are medicaid, it costs them more to provide the service than the reimbursement. something needs to be done about that, if we expect psychiatrists and other health care providers to see medicaid patients. >> i want to start with questions. we'll start over to the left. you can he be free to address questions to individuals or throw it out to the general panel. >> great.

my name is laura truman, i work for house majority whip steve scalise. we just became a cosponsor of mr. murphy's bill and very excited at that and feel like that helps on the front end so people get care and don't end up in jail. criminal justice reform, all the discussion represent a really great opportunity for to us do something on and having reviewed a number of the bills i don't think we're quite doing enough. we have things like you know, steadyies and things that would encourage more mental health courts but i'm not sure there is a big enough carrot or stick there that would address what happened last week with the young man in virginia, et cetera. would you all have ideas, respecting federalism, to some degree, not big footing totally

but, doing better than we are with some of the proposals on how we can encourage states to prioritize, making sure that these folks don't end up in jail? >> well, very important topic, thank you very much for the work you do. as i mentioned earlier, this is an area, criminal justice reform, where there is bipartisan conversations going on right now. it is very heartening to see those conversations as we think about the relative role of our jail and prison systems, as they play in keeping our communities safe. i would highlight a bill that is also in congress now, the comprehensive justice and mental health collaboration act which does fund along a continuum the type of services and interventions that have been associated with assisting individuals with mental illness stay out and avoid involvement with the criminal justice system. that is bipartisan with support

that is there. senator franken and cornyn introduced the bill. it is really important i think federal incentive for communities around the country to develop these effective responses. >> thank you. seeing no questions on this side we'll go back to the left. >> my name is bernie errands. i'm a psych key tryst. -- psychiatrist. and i used to work with smsa. working at a crosswalk between federal legislation and work that advocates and mental health professionals do. you have raised some very important areas that need attention. crisis intervention teams. criminal just disdivergence programs, mental health systems in jails and prisons, expansion of the and training of the mental health workforce and i'm

wondering whether the attention to federal legislation helps accelerate the implementation of those programs or diverts our attention in a way that makes it, that may prolong that? i wonder, for example, if attention to how the bureaucratic boxes are structured in the federal government is where efforts should be spent or somewhere else? so i would be interested in your thoughts on whether you find the federal legislation helpful in the advocacy and professional work you do-or-die version in some ways we need to be worried about? >> thank you. >> i think i can tell you pretty clearly, having a senator not only know what imd stands for but talk about it on a stage is amazing. to have congressman murphy go county to county talking about fixing smsa and fixing the mental health system is amazing.

we never had exciting time as we have right now, this momentum to finally reform the mental health system, if this is a problem i would love to have more of them. >> i want to add i think the efforts are complimentary. you mentioned cit. there are federal bills to add resource there is but we also work at the state level at nami trying to get statewide technical assistance around those programs to bid them up. i think federal attention only compliments what we're trying to do at state level as well and provide resources that can serve as a catalyst to that. i see efforts both local, state level and nationally complimentary. fred mentioned step up campaign that is focused at a county level, the local level but the work we're doing on capitol hill, we held a briefing on capitol hill to talk about that. i think they're very complimentary. >> i think we also heard a number of examples that come from the state level. there is some innovation. that is how our country works. we innovate at state and local

level. we learn from that at the federal level and reinvest the dollars where it can best work. i think whatever the federal structure we have to keep that living. it can't be a single solution. i think it does come, does come out in different ways and different types of things work in different communities, rural, urban or different places where there is different kinds of challenges or opportunities. i think as we continue conversation at federal level which is vital from a research perspective and from the regulatory framework perspective, we have to continue to find those great examples at the state and local level and share them to drive that innovation. >> this is an incredible moment in history, if we think about it, to have the support of republicans and democrats, to have a bill in the house of representatives and a bill in the senate and for people being motivated to work together on both sides of the aisle, to

really do something, highlight the fact that our current system is broken and that we can fix it. we can fix it federally and we can fix it at the state level. so i'm very excited about this. >> thank you. we'll take a question from this side of the room. >> thank you. i work on the senate health committee. i know we talked a little bit before about early intervention. you could talk more to that, early screenings, children in school, nutrition office is doing that, a little more what those kind of screens may look like. >> thank you. >> i can, do you want to go ahead? >> you can go. >> okay. i was saying we are seeing those kinds of innovations in medicaid. it takes a little bit of a switch in thinking because you're not diagnosing something. you're diagnosing something that may happen. it's a change to our system, how we think about getting people into different programs but we are seeing that kind of focus.

but it's a challenge. so i think we need to be thinking about how do we put people into some of these programs. i also know a lot when we talk about with children or young adults, classification is a concern. and when you move that into giving them labels, we really have to be cautious about how we do this? and when we're doing this in the health care system that information will travel with that person. it is just something where the dynamic i think we're working on but it is happening. >> thank thank you. >> i just want to add where imh is doing, young adults early experiencing psychosis is so important. that approach is very different. it approaches people with, what do you want to accomplish in your life? how do you support that through supportive employment and education as well as treatment and education and therapy and it includes family. one of the issues will we be able to finance that going forward?

financing it with medicaid? financing it with private insurance dollars? it is such a wonderful approach for people first experiencing these issues. i had the privilege to go to one of these programs. it is very different than regular health center. i walked in, saw a ping-pong table. young adults were cooking and laughing and had a very different feel to it. that is why it is so successful. imh will come out with data soon on that. that is important program for people to people to focus on. it is a great service and should spread. everyone who has access to cronic illness has access to that service. >> one more question. >> very quickly my son died this year after age 23 of heart failure after a seven-year battle with schizophrenia. i'm director of parents for care in baltimore, maryland, i get phone calls every week,

desperate emails every week, i can't get my child care, right? we all know parody is really the issue and i would say illegal discrimination or rather legal discrimination rather than stigma. what i want to know, parent mention to me all the time, i used to mention this during johns hopkins in treatment. insurance won't keep my child in the hospital why don't we sue them. why don't we sue them for medical parity? i can't think of a lawsuit. state of california has one going to forts parity. what are your thoughts on that? >> i totally agree with you. the american psychiatric association is involved in the lawsuit in california and there is a lawsuit in new york. bringing lawsuits can be very, very effective. i'm really sorry to hear about your son. i'm sorry about your loss. i think you raise a point about

comorbidity between mental illness and psychiatric illness. when someone comes in for cardiac problems they could have mental health screening. certainly when someone comes in for mental health problems, it is not just a problem of the mind. there are all kinds of associated physical issues and a person is a whole person. we need to take care of the whole mind and the whole body and the whole brain. >> these sort of event are so vital. i think if you talked to a person on the street they would have no idea about things like same day billing. about the idea you're not able to get physical care the same day you get mental health care. any of these issues we're talking about, it is simply not on people's radar. the more we talk about realities what you deal with -- you hear so often, why didn't the family just get him help? having no idea families have no

options and we need more solutions. this is the best way to do it, bring the issues up to have these discussion. >> we sue for everything else. >> thank you so much. i want to thank our panel for their insights and help. i really appreciate it. thank you so much. >> thank you. [applause] >> bless welcome back, the senior vice president of "national journal." >> thank you so much, to lauren and to our panelists and speakers today. very special thanks to janssen pharmaceuticals. at this time i would like to invite michelle goodrich, from janzen pharmaceuticals to the podium for closing remarks. [applause] >> i just want to thank everyone here for their amazing engagement and participation in the discuss today. special thanks to all of our speakers for a very thought provoking discussion.

special thanks to our audience members who shared very courageous stories. thank you for doing so. janssen, is proud to be part of what they consider this very important conversation to champion better solutions for people with serious mental illness on path to recovery. janssen has a committed to deliverying medicine for mental health that spans 50 years. our organization remains at the forefront of advancing central nervous system treatments and improving care for people with brain disorders. and we will continue to invest in finding innovative treatments an developing solutions that improve patient outcomes. so at the same time, we do recognize that pharmacological treatments are but just one element of putting people with severe mental illness on their path to recovery. within the larger ecosystem of patient care. so the legislative and

community-based solutions we've been discussing today we think are critical to insuring that individuals with mental illness are supported and they get the best chance they deserve to hold meaningful lives. so early diagnosis and intervention from the medical and mental health community are particularly important. and may result in better health outcomes, reduced costs to those with mental illness, their families and to our broader society. so as you have heard today, the collaboration between the mental health and criminal justice systems we think is critical to improving lives and reducing costs for both patients and public systems. we really applaud and think and support legislative efforts to reform our mental health system. together we do believe we can find the best and most collaborative solutions that create a win-win for all. so thank you again for being here today. and for being part of this very important conversation.

[applause] >> today a discussion on the economic, political and security challenges in the kurdish region of iraq. we're live at noon eastern here on c-span2. coming up today, a discussion on the life and career of former british prime minister margaret thatcher on what would have been her 9th birthday. we'll be live with the heritage foundation at 4:00 p.m. eastern on c-span. c-span has your coverage of the road to the white house 2016 where you find candidates, the speeches, the debates and most importantly your questions. this year we're taking our road to the white house coverage into

classrooms across the country with our studentcam contest, giving students the opportunity to discuss what important issues they want to hear the most from the candidates. follow c-span's studentcam contest and road to the white house coverage 2016 on tv, on the radio, and online at c-span.org. the health care open enrollment period begins november 1st. next, the alliance for health reform looks at the cost of various plans available in the insurance marketplaces across the nation. this is an hour and 15 minutes. >> okay. we're going to go ahead and get started. welcome to today's briefing on

the third open enrollment period which is, i'm sure everybody in the room knows begins november 1st. we're going to be talking today about what to expect, premiums, deductibles, other costs, trends in the kinds of insurance products that will be offered, challenges in signing up remaining uninsured population, and a whole lot more. on behalf of our honorary co-chairman, senators ben cardin and roy blount i would like to welcome you and thank the commonwealth fund for being our partners in this event. moderating with me today is sara collins to my right. she is vice president of the health care coverage and access program at commonwealth. i'm going to introduce the rest of our speakers. to my far left is john gabel, senior fellow at norc at the university the chicago. cori uccello, actuary at american academy of actuaries. on the other side of sara,

carrie banahan who comes from kentucky. she is responsible for implementation and operation of kentucky exchange. to my right, mila kofman had a shorter commute. she is executive director of the exchange. if you're watching us live on c-span2, we welcome you and encourage you to tweet your questions to us. we will try to get them to our speakers to answer today. you can use the hashtag, oe3. you can be live the tweeting today. we welcome you to live tweet with us. the hashtag is oe3. i will turn it over to sara collins with the commonwealth fund. >> thank you, marilyn. i behalf of the commonwealth fund i want to thank the alliance and thank the panelists for coming today and extend a warm welcome to the audience this afternoon. looking ahead to the 2016 open

enrollment period an estimated 29 million people remain uninsured. hhs estimates 10.5 million people are eligible through the marketplaces n addition about nine million people currently have coverage through the marketplaces. most, if not all, are likely going to want to reenroll. to gain some insights into what both current and perspective enrollees might be thinking about as they consider their options this year i will share some recent findings from the commonwealth's found affordable care act tracking survey which we field the at end of 2015 open enrollment period in the spring. i will focus if particular on issue of affordability. i will highlight data about costs people faced by people currently enrolled in the plans. how they compare to costs in employer-based plans. i will look at how affordability factors into people's decisions

about health plans when they shopped in the marketplaces last year. i will just need -- in our analysis of the survey data we found that premium costs for people with marketplace plans are comparable to those with employer plans among low and moderate income adults but fewer people in marketplace plans said it was easy to afford their premiums compare to those employer plans. although differences were narrow among people with low and moderate incomes. with regard to deductibles, people in marketplace plans had higher deductibles on average compared to those in employer plans but again, differences were narrow among adults with low and moderate incomes. among marketplace enrollees, premium costs were most important factor in their choice of a plan. affordability was the top reason

given by adults who shopped in the marketplaces but didn't end up enrolling in a plan. about 60% of adults with health plans they purchased through the marketplaces paid about $125 a month or nothing for single policies. a similar percentage of people enrolled in employer plans reported they had paid that much. the similarity is due to the fact that most marketplace enrollees were eligible for subsidy and didn't pay the full premium. likewise, most employers pay part of their employee's premiums. the effect of subsidies was most pronounced for people earning less than 250% of poverty level. people with higher incomes in marketplace plans paid more and more than people in employer plans. this is because the amount of the premium subsidy in marketplace plans phases out at higher incomes. people pay increasing amounts

premium as income rises. overall adults with marketplace plans consider their health insurance to be less affordable than people who have employer coverage. the differences in perceptions of affordability between adults in marketplace and employer plans were wider among higher income adults than they were among lower income adults. people in marketplace plans on average reported higher deductibles than those in employer plans. 43% of adults in marketplace plans had per person deductibles of $1,000 or more compared with 34% of the adults in employer plans. differences in dedoublables in market based plans and employer plans were wider among higher income adults than they were with lower income adults. this is likely with people incomes lower than 250% of the poverty with silver plans are available with cost sharing

deductible subsidies that lower out-of-pocket and co-pays. premium costs on average mattered more to people when they were choosing a plan than either the dedickable or whether their doctor was in the plan's network. consistent with this finding, we found that more than half of marketplace enrollees who had option chose a plan with a limited or narrow network of providers in exchange for a lower premium. among people who visited the marketplaces but didn't enroll in the plan, affordability was a key factor in their decision to walk away. 57% of adult who is visited the marketplaces but did not enroll said they could not find a plan they could afford. looking a little more closely at this group of adults who told us they didn't enroll because they couldn't afford a plan, and also excluding people who gained coverage someplace else, 26% were living in a states that

hadn't expanded medicaid and had incomes under 100% of poverty which meant they weren't eligible for premium subsidies. more than half of those who couldn't find an affordable plan had incomes in the range that made them eligible for the subsidies. people who shopped in the marketplaces but did not enroll had greater difficulty comparing features of health plans like premiums and out-of-pocket costs compared to people who did enroll. 50% said it was difficult to compare the premiums of different plans. 60% of those who didn't enroll said it was difficult to compare plans by what potential out-of-pocket costs might be. receiving personal assistance appears to make a different in whether people enroll. when we controlled for demographic differences, we found that 78% of adults who said they received some kind of assistance ended up -- marketplace plan or medicaid. in contrast, only 56% of those who did not receive assistance enrolled.

just to recap -- insurance may not have information they needed to help buy coverage. many had difficulty comparing basic features of plans. personal assistance does appear to help people enroll but the lack of medicaid expansion in 20 states is clearly an insurmountable barrier for poorest residents in the states. i will stop there and look forward to your questions. >> great. so, if you were in the room with us, you have the results of these tracking surveys that sara is discussing in your folder on

the left side. if you are not in the room with us you can still access these materials on our website, www.allhealth.org. i will turn it over now to jon. let me point out for those standing, there are seats on the other side of room. >> thank you, marilyn. i also would like to thank sara and the commonwealth fund. would also like to thank sara and the commonwealth fund for making this work possible. i also would like to thank ed howard for his many years of service, bringing the work of the research community to the policy community. did i just? oh.

let's go back. this is a history of employer-based health insurance since 1988. i show it to provide context for the historic record. now you may be asking right now, why are you showing employer-based insurance? why not individual insurance? and the answer is simple. because we are incapable of showing that record for individual insurance. but i want to emphasize three points. number one, there is a history of volatility. take 1989. premiums increased 18% that year. secondly, premiums almost always outpace increases in workers

wages and the overall consumer price index. so now let's turn to results for exchanges. this is early information, very early information. it is limited to five northeastern states. most of them are very small states. it is also why these five states because these are the states which have posted all the information so far on their websites. when i say all that information, i'm talking cost sharing information in addition to premiums. so currently, on these five states, we note that the average increase is 4.9%. and the median is 2.1%. now i would also add that

mckenzie says the number of carriers coming into the marketplace this current year will be up. it looks like it is up for at least 10% for the last year. that may have a dampening effect on premium increases. if we look at the benchmark plan, and the benchmark plan is so important because it is basis for what the federal government will pay and also the basis for what enrollees will pay, we see average increase is 6.7%. . .

>> and these, this increase in deductibles has held down premium increases. on the exchanges, we are not seeing much change. we're seeing, on average, a drop of about 5.9% many, and the median is 3.3%. another important point of cost sharing is the out-of-pocket max. and here we're seeing the max increase 5.8%, but it's almost entirely due to maryland. the median increase is 2.3%. so let me summarize what these

early returns are, how typical are these five states to the rest of the nation, it's really very difficult to say. what we do know is there are great differences from state to state. last year ten states had double-digit increases, and according to our data, the overall increase was 0%. so the average -- if this is what i dare say based on early returns -- number one, average premium increases will be higher than last year. benchmark plans show greater increases than the average increase for silver plan. the averages are going up, but they're not -- it is not a catastrophe as some have reported. what instead we're seeing is something more in line with

employer-based health insurance where the historic average is around 7%. where we have been at 4% for about the last four years. and lastly, cost sharing remains stable. thank you. >> thank you, jon. we'll move now to corey you can cello with the american academy of actuaries. >> thank, jon, and thank you to the alliance and commonwealth fund for inviting me to participate today. so jon provided an overview of general premium trends, and now i'll give you some information on the drivers that may be underlying these trends. before i get to that, just a quick reminder of the components of premiums. claims make up the largest share of premiums, and they reflect not only who has coverage, but also what their medical spending is. other premium components include administrative costs and profit, and of course, laws and regulations can affect each of

these components. so i won't get into this slide in detail, but i just wanted to highlight some of the elements in the premium development process. so one thing that insurers have to do is to determine their plan designs and perform actuarial value testing to make sure their plans fall into one of those metal tiers. another thing they have are to do is examine their prior claims and enrollment experience, make necessary adjustments and then project that information forward to 2016. i'll talk a bit about what those adjustments are in a minute. insurers also have to negotiate with providers to get their provider payment rates. so i'll talk about three major drivers of 2016 premium changes. the first of these is medical trend which is the underlying growth in health care spending. now, although medical spending

has been relatively slow recently compared to historical trends, prescription drug spending has been increasing fairly rapidly due to the introduction of specialty drugs. on average, 2016 premiums reflect a medical trend of about 6-8%, and the prescription drug trend of about 10-12%. the second major driver of premium changes for 2016 is the scheduled reduction in the reinsurance program. so the reinsurance program subsidizes plans for their high-cost enrollees, and it does so by offsetting some of those high-cost claims. by offsetting claims, the reinsurance program then lowers premiums. but the reduction in the reinsurance program means that there will be a lower offset to claims, and that lower offset will in turn produce some upward pressure on premiums.

and on average, the reduction in the reinsurance program could increase 2016 premiums by about 3-5%. here's more detail on the reinsurance program parameters and how they're changing over time. the third major driver of premium changes is how the expectations regarding the 2016 risk pool profile differ from those that underlie 2015 premiums. so as a reminder, when insurers put together their 2014 premiums, they didn't have a lot of information to go on in terms of who would enroll in coverage and what their health spending would be. in 2015, for that plan year, insurers had a little more information to go on. they just had the first few months of enrollment in 2014. now, looking forward to 2016, insurers have a lot more information on their own

experience for 2014 in terms of who enrolled in coverage and what their health spending, health spending is. they also have a few months' worth of data from 2015. and if they have more information, they're able to change their assumptions regarding 2016 accordingly. and these changes in assumptions can either lead to higher or lower premiums. so i noted earlier the need to adjust prior experience data when projecting that forward to 2016. so in 2014 enrollees who were more likely to enroll early, in january, for coverage were those who would be more likely to have high health care needs and have high health care spending, whereas those individuals who are healthy may have been more likely to delay coverage to later on in the open enrollment period. so that's one thing that needs to be adjusted for.

another adjustment might need to be made to reflect pent-up demand. people who have, who are newly insured in 2014, those who are uninsured in 2013 who then gained coverage in 2014, might experience a temporary spike in their spending based on pent-up demand. they put off obtaining services until they got coverage. now, some of that will be temporary. it's not expected to kind of be at that high level permanently. so not accounting for these two things in terms of enrollment timing in 2014 and the pent-up demand, if those aren't accounted for, this could result in an overestimate of 2016 claims. insurers might also need to adjust the risk profile expectations if they think that the increase in the individual mandate penalty will lead more people to obtain coverage

especially among the healthy folks. an influx of people who have lower health care needs could actually put some more downward pressure on premiums. so jon's slides showed how premium changes can vary across states. and one of the reasons for this is the transition policy which allowed individuals to hold on to their non-aca-compliant coverage. sometimes this is referred to as grandmotherred plans. many, but not all, states adopted that transition policy. so in states with that who did have the transition roll policy, people who kept their old plans might have been those who were more healthy, because they might have gotten lower premiums, and they didn't necessarily care about pre-existing conditions, exclusions or things like that. so they may have kept their old coverage, whereas people who had high health care needs, had a lot of pre-existing conditions and maybe previously had been

rated higher because of some health conditions, they would be more likely to switch into the new aca-compliant coverage. so states that adopted that transition role might be seeing higher premium increases than plans in states that did not. and finally, i just want to point out that, you know, we hear a lot of information that's coming out just in the past couple weeks regarding premium changes, but i want to caution you that this is really just looking at averages either in the state as a whole or for particular insurers. but what a particular consumer faces in terms of his or her own premium change is likely going to differ from that average. the premium change that a consumer faces will reflect that consumer's particular plan, that consumer aged a year, so right away that's going to result in an increase in premium. consumers can also have changes in their premium subsidy

eligibility, and they may have other changes as well. so those are kinds -- it's things to keep in mind when comparing a consumer's individual premium change as opposed to the change in the market as a whole. thank you. >> great, thank you, cori. we'll turn now to carrie banahan with the kentucky exchange. >> thank you for inviting me -- sorry about that. thank you for inviting me here today to talk about kentucky's health benefit exchange, connect. as the state-based exchange, kentucky was able to develop an integrated eligibility system with online, realtime determinations of eligibility for medicaid and qualified health plans. this is why we were able to enroll over a half a million people into coverage for the first time. this resulted in a decrease rate of the uninsured from 14.3% to

8.5% based on some recent u.s. census data. this was the largest decrease in the nation. based on a gallup poll on the first half of 2015 for individuals under age 65, we decreased the rate of uninsured from 20.4% to 9%, and that was the second largest decrease in the nation. prior to the affordable care act, kentucky basically had two insurance companies in the individual market. when we launched connect in 2013, we had three inyouinsurers that offered products on our exchange. due to our success in 2015, we had two additional insurers -- care source and well care -- and we're very excited to say for 2016 we're going to have eight

insurance companies offers products -- offering protects. we've added aetna, united health care of kentucky and baptist health which was formerly known as blueass family health. you know, without the affordable care act cayennes would not -- cayennes would not have these additional choices. outside of the exchange in our regular commercial market, there's about two or three additional insurers that are going to offer products. in kentucky we plan to have a passive renewal process. individuals can remain enrolled this their current health plan -- in their current health plan, and they don't have to do anything at all. october 1st we issued a noticed a vising individuals that open -- advising individuals that open enrollment was coming up, that we were going to have more insurers and more health plans on the exchange.

around october 21st we plan to mail out our open enrollment packet. it will include the individual's premium amount for 2016 if they keep their coverage as well as their aptc amount. however, we are encouraging everyone to check out all of their options because of the new insurers and new plans that will be available. as part of the passive renewal process, we'll be accessing the federal data service hub to verify income. if we're unable to verify income, we'll issue an rfi requesting documentation of their income, and as a new feature of our system that we implemented in 2015, if they don't provide proof of their income within the 90-day period, we'll utilize what is on file with the irs.

for 2016 we're implementing several system enhancements that will improve the consumer shopping experience and assist the consumer in selecting the best qualified health plan options that meet their needs. during open enrollment two, we identified thousands of individuals who had purchased a gold or platinum plan, and they were actually eligible for cost-sharing reductions if they would have selected a silver plan. as a result, we sent out a letter to these individuals in december notifying them of the availability of cost-sharing reductions if they selected a silver plan. since that time we've develop canned system functionality -- developed system functionality in plan browsing as well as our regular shopping where these silver plans will be displayed first if you're eligible for a cost-sharing reduction. we also have special messaging

strongly encouraging individuals to select a silver plan on our screens if they're eligible. at the request of the agent community and our in-person assisters, we'll be launching a tablet application in the individual market as well as for medicaid enrollees and shop. the tablet application allows the user to enroll from start to finish. it also utilizes an intuitive and conversational process. many kentucky-- do not select the best plan that best suit their needs. we've seen individuals buy a platinum and a gold plan who hardly ever go to the doctor, and we've seen people purchase a bronze plan who are heavy utilizers. as a result for open enrollment

three, we've developed a cost-shopping tool to assist individuals in selecting the plan that best meets their needs. with this new cost-shopping tool, individuals will enter their medical condition -- diabetes, asthma, copd -- they'll also be asked to rate their health status from poor to average to good. they'll also include any health care providers that they're seeing, their physicians, maybe the hospital that they go to, frequency of physician visits will also be collected, and they'll also enter any type of prescription drug medication that they're taking. we also ask them if there's a future be medical need -- future medical need such as a hip replacement or a knee replacement, they would enter that information on the system as well. and based on all the information that is entered, the system will

display the best value option for the applicant. in 2014 we had a connect retail store at the mall located in lexington, kentucky. it was highly successful. we had over 7,000 visitors. we took almost 6,000 applications. local agents, in-person assisters and state staff helped with the store. and we'll also be having a second store for this open enrollment in louisville, kentucky. for open enrollment 2016, we'll be conducting statewide outreach and education and advertising through various channels; tv, radio, cable, billboards, print media, social media. but we'll also be targeting

certain populations with tailored messages. in rural counties there are 18 that probably have a higher uninsured rate than we would like, so we're working with the university of kentucky rural extension offices hosting enrollment events with local agents and in-person assisters. we're also running newspaper and radio advertising in those counties. we've targeted 32 counties in kentucky with low dental health. we'll be distributing 10,000 toothbrushes to dental clinics and schools in those areas, and we're going to increase our efforts in marketing dental plans that are offered through connect in those counties through increased advertising. individuals on transitional and grandfathered plans who could obtain their coverage through connect and receive a discount

are being targeted as well. we sent out mailers to households. we're running tv ads and commercials advising of discounts through connect. that's the only place you can receive a subsidy, is on the exchange. and we also have early renewal fact sheets available instructing people how they can enroll true special enrollment -- through special enrollment. we're targeting the justice involved population. we're working with our statewide healthy reentry coalition comprised of correction personnel, federal, state and county. advocates and connectors are also on this project as well. and we've actually produced a 2-3 minute video by former inmates educating individuals about the importance of health insurance coverage once you're released fromç prison and on hw you can actually obtain that

coverage by enrolling through connect. we've allocated resources to the prisons and the jails for education and enrollment. and it's important for the justice population to continue a course of treatment or medications once they're released, and these efforts will help insure that they enroll in coverage as soon as possible and continue their treatment. mila, i couldn't have timed it any better. >> fantastic. so we're going to turn the microphone over to mila kofman with the d.c. exchange, and i want to remind you that if you're following us on twitter, that the twitter handle is hashtag oe3. we welcome your questions that way or comments as well. after mila finishes her presentation, we're going to turn to q&a, so start getting your questions ready. you'll be able to ask your questions both -- we have two microphones set up in the room, or you also have a green card in

your packet on which you can write down questions, and our staff will be circulating around the room and will pick them up and bring them to us. and, of course, again, if you are not in the room with us and you're following on c-span2, you can tweet your question at hashtag oe3. mila. >> thank you so much. first of all, thank you to dr. collins and the commonwealth fund for continuing to do research and invest your research dollars into work that actually informs people on the ground. very much appreciate your ongoing effort. not only in forms, but influences our approach on the ground. and i'd like to also thank ed howard for his many years of leadership. he, i'm sure, mentored many people in this room including myself, fresh out of law school. so his leadership and his contributions we will miss, and maybe he'll reconsider retirement.

[laughter] so the affordable care act is working in the district of columbia just like it's working in kentucky and in most states. we, according to the census, our uninsured rate dropped by 20%, and in the district of columbia, as many of you know, we had a very low uninsured rate for many years. through the years we've invested a whole lot in coverage expansion and expansion to medical care efforts. so my whole team was very proud when the census report came out that it really did matter that we were on the ground finding the hard-to-reach population. we're not done yet, and we won't stop until every single person, child, individual who lives in the direct or works in the district -- lives in the district or works in the district has access to

affordable, quality health coverage. since october 2013 when we opened for business, over 166,000 people have come through us on the individual marketplace side, over 24,000 people have come through us. on the medicaid side, over 120,000 people were found eligible for medicaid. we have no wrong door policy, that means you complete one application online, and instantly you'll get your medicaid eligibility or eligibility for aptc. and on the small group side, we've had over 21,000 people come through us which includes members, certain members of congress and designated staff. so folks here from the hill who are my customers, thank you very much for being my customer. [laughter] on the individual side, we have a very healthy risk mix.

you often hear that if you only insure older people with lots of claims, premiums will be very high. we tried very hard to make sure that people who are insured through us are young and older and everyone in between. our biggest by age category insured pool is 26-34-year-olds. it's 41% of our individual enrollment. we also have pretty diverse population choosing diverse levels of coverage. although bronze is 29% as you can see, gold is 23%, and 18% of our enrollees are in platinum plans, and that's all on the private individual side. small group side, that is not including congress, the largest and most popular level of coverage for us is platinum, 48% of small groups are in platinum

coverage, and 32% are in gold. we offer full employer and employee choice. that means the small business can choose a choice of carriers and a choice of products for his or her employees. and, in fact, about two-thirds of our small businesses offer choice to their employees. out of the 840 employers that we looked at, two-thirds offer a choice of carriers by choosing metal levels and letting the employees choose which carrier they want to be enrolled in or offering all products from the same carrier, and that means employees can choose all levels from that carrier from bronze to platinum. our role is to advocate for all of our customers, and we advocate for the lowest possible

premium rates. we have outside actuaries who review rate filings and provide external analysis to the insurance regulators arguing for the lowest possible premium rates through d.c. health link. we also advocate for our customers by empowering our customers to have access to all commercially-available products from all carriers doing business in the district of columbia. as we go into this open enrollment period, we are deploying many new tools for our customers that we didn't have before. we're thrilled that we're able to launch an all-plan doctor directory. the english version is up on our web site and spanish version is available in beta on our web site. we found that there's been a whole lot of bait and switch when it comes to doctors and relying on directories available

from each carrier. they're not always up-to-date, and when a customer makes a decision about the health plan based on his or her physician participating and then later find out the physician is no longer participating, it may be too late to switch plans because open enrollment is done. so the all-plan doctor directory is designed to help our customers have access to better information. we've also a couple of weeks ago launched d.c. health link plan match, and that is powered by the washington consumer checkbook. it is very similar to what carrie described for kentucky. a person -- our customer or potential customer, you don't have to have an account with us, can just go on d.c. health link.com, put in your age, put in how many family members you want to cover, put in your basic health status if you think you're in good health or excellent health or poor health,

any anticipated medical needs in the following year and any doctors that you're seeing, and the tool will give you all health plans ranked in order. it will give you your total out-of-pocket anticipated cost including the premium, the coinsurance deductibles and co-pays, and it will give you that for an average year as well as a bad year. so we believe that kind of consumer empowerment tool will help our customers make better decisions. next year we're going to have 136 different group health plans and 26 different individual plans. and so when you have that many options, we know and literature shows that it's just overwhelming. and we heard that from our customers currently, we heard it from our broker partners, our navigators and assisters. so we're really excited about

that new tool. next year we'll be launching something similar for shop. next -- for 2016 we'll also have new standardized plans. that means standardized benefits as well as out-of-pocket expenses that will help our customers make more informed decisions, compare apples to apples. in our first year of operation, we had semi-standard products meaning the benefits had to be the same in the essential health benefits benchmark, no substitutions, but co-pays and other out-of-pocket costs varied. and although that was helpful to our customers, it wasn't the complete tools that some needed to make good decisions. we, like kentucky, experienced the same thing. some folks chose platinum when theyad